Research Paper

Drug utilization pattern and pharmacoeconomic analysis in geriatric medical in‑patients of a tertiary care hospital of India Binit N. Jhaveri1, Tejas K. Patel2, Manish J. Barvaliya1,3, C. B. Tripathi1,3 Department of Pharmacology, Government Medical College, 3Department of Pharmacology, Bhavnagar, 2Department of Pharmacology, Gujarat Medical Education Research Society Medical College, Gotri, Vadodara, Gujarat, India


ABSTRACT Objective: To evaluate drug utilization pattern in terms of defined daily dose along with pharmacoeconomic analysis in geriatric patients admitted in medical ward of a tertiary care hospital. Materials and Methods: Retrospective medical record analysis was performed for indoor cases of the geriatric patients (age ≥65 years) admitted in medicine ward from January 2010 to December 2010 were analyzed for demographics, indications for admission, various systems involved, duration of hospital stay, various drugs prescribed, and adverse drug reaction. The drugs were categorized by anatomical therapeutic classification and defined daily dose was calculated. The World Health Organization prescribing indicators were assessed. Cost of the drugs was calculated to assess the economic burden. Results: Cardiovascular diseases were the common cause for admission. Antiplatelet drugs‑B01AC (93%), H2 blockers‑A02BA (77.22%), antiemetics‑A03FA (67.6%), vasodilators‑C01D (55%), and hypolipidemic drugs‑C10AA (52%) were commonly utilized groups. Average number of drugs per patient was 9.37 (95% CI: 9.09‑9.64). Average number of antimicrobials prescribed per patient was 0.91  (95% CI: 0.82‑0.99). Cefotaxime was the commonly prescribed antimicrobial drug. Average cost of treatment was `540.5 (95% CI: `458.0‑623.0). Patients shared 45% of the economic burden for prescribed medicines. The average economic burden for drugs was significantly higher in expired than survived patients (`749.49 vs. 457.59). Conclusion:  Polypharmacy and irrational use of medicines are common problems in geriatric prescription. Prescription guidelines should be formatted for them. Key words: Drug utilization research, geriatric population, pharmacoeconomic, polypharmacy, prescription audit, rational use of medicine, retrospective study

INTRODUCTION Access this article online Quick Response Code:


DOI: 10.4103/0976-500X.124411

The elderly population is increasing rapidly worldwide. Their growth rate (1.9%) is higher than general population (1.2%).[1] At present, India is the third country after China and USA with large elderly population in the world. Elderly population has special problems related to health, social support, and economic security. Their healthcare need differs from younger people. Though elderly are reported to be responsible for half the total drug usage, less than 5% of randomized control trials have been designed for them.[2] Therefore, data available from younger

Address for correspondence: C. B. Tripathi, Department of Pharmacology, First Floor, Government Medical College, Near S.T. Bus Stop, Jail Road, Bhavnagar ‑ 364 001, Gujarat, India. E‑mail: [email protected] Journal of Pharmacology and Pharmacotherapeutics | January-March 2014 | Vol 5 | Issue 1


Jhaveri, et al.: Drug utilization and pharmaco‑economic analysis in geriatric patients

subjects are used to guide prescribing in elderly. Physiological and pharmacological variations in elderly population include decreased total body mass, blood flow to various organs, immunity, and nervous functions; down‑ or upregulation of various receptors; and disturbance in first pass metabolism, bioavailability, metabolism, and excretion. [3,4] Presence of comorbidities in elderly people require use of multiple medications which increase the irrational prescription, use of inappropriate medications, noncompliance, economic burden, adverse drug reactions (ADRs), and drug interactions.[5] The overall incidence of ADR is two to three times higher and most of them are potentially avoidable in elderly patients.[6] These hurdles in pharmacotherapy can be overcome by periodic evaluation of drug utilization and optimizing prescribing pattern by forming prescription guidelines for geriatric patients. Drug utilization research is an important tool to analyze the use of drugs with special emphasis on medical, social, and economic consequences in a society.[7] The assumed average maintenance dose per day for a drug used for its main indication in adults is called defined daily dose (DDD).[8] It is an internationally accepted tool for comparing drug utilization. The present study evaluated drug utilization pattern in terms of DDD along with pharmacoeconomic analysis in geriatric medical in‑patients.

MATERIALS AND METHODS This retrospective study was conducted after permission of Institutional Review Board, Government Medical College, Bhavnagar, Gujarat, India. Indoor cases of geriatric patients (age ≥65 years) admitted in medicine ward between January 2010 and December 2010 were collected from medical record section of Sir Takhtsinhji General Hospital, Bhavnagar. Data were collected for demographics, diagnosis, hospital stay duration, treatment, outcome, and documented ADR. Data were analyzed for age and gender distribution; common indications for admission and systems involved, hospital stay duration, and total number of drugs prescribed per patient. Drug utilization pattern was evaluated by proportion of patients receiving particular drugs, its pharmacological groups, anatomical therapeutic classification (ATC) code, and DDD/100 bed‑days using following equation.[8]

Total dose in mg during study period × 1000 DDD/100 bed days = DDD of drug × study duration (days) × bed strentgh × Avg. bed occupancy rate

The bed strength and average bed occupancy rate were 30 and 0.3, respectively for geriatric patients in medical ward. 16

Other prescribing indicators like total number of antimicrobial drugs per patient, proportion of fixed dose combinations (FDCs), use of drugs by generic and brand, oral and parenteral formulations, National and WHO Essential Medicine Lists,[9,10] and costliest drugs were evaluated. ADRs were assessed for causative drugs by Naranjo’s algorithm, severity by Modified Hartwig and Siegel Scale, and preventability by Modified Schumock and Thornton criteria.[11‑13] Cost of generic and brand drugs were calculated from hospital formulary and Indian Drug Review (2010), respectively. Cost of laboratory investigations, ward charges, and nursing care were not included. Statistical analysis Data were expressed as proportions and mean (95% confidence interval (CI)). Mostly descriptive statistics was used. Comparisons of categorical and continuous variables between survived and expired patients were done using Chi‑square and unpaired t‑test, respectively. Hospital stay and economic burden were compared between common geriatric diseases by one‑way analysis of variance (ANOVA) followed by Tukey‑Kramer multiple comparison test. All the statistical comparisons were done with GraphPad Instat 3.0 (Trial Version). P < 0.05 was considered statistically significant.

RESULTS Total 12,227 patients including 706 (5.77%) geriatric patients were admitted in medicine ward. Total 30 patients who were admitted only for observation were excluded. Total 357 (52.12%) patients were female among the 676 included. Mean age of geriatric patients was 72.69 years (95% CI: 72.12‑73.27). Average hospital stay was 5.07 days (95% CI: 4.80‑5.34). There was no significant difference among male and female (4.80 days (95% CI: 4.43‑5.18) vs 5.31 days (95% CI: 4.92‑5.69); P = 0.067) for hospital stay. The five most common conditions for admission were ischemic heart disease (IHD, 39.49%), hypertension (37.27%), cerebrovascular (CV) stroke (27.81%), diabetes mellitus (18.49%), and congestive heart failure (CHF, 14.79%). Multiple systems were involved in 57.25% patients. Cardiovascular system (80.02%) was the most commonly involved system followed by central nervous system (22.18%), hematological (19.23%), endocrine (18.63%), respiratory (18.04%), renal (15.53%), gastrointestinal tract (7.84%), and genitourinary system (2.95%). Total 6,314 drugs were prescribed in all the cases with 45.1% parenteral, 47.2% oral, and 7.7% other formulations. Total 207 different types of drugs were prescribed by generic (48.79%) and brand (51.21%) names. Parenteral formulations and fixed dose combinations  (FDCs) were prescribed in 25.60 and 17.87% of patients, respectively. Total 101 (48.79%) and

Journal of Pharmacology and Pharmacotherapeutics | January-March 2014 | Vol 5 | Issue 1

Jhaveri, et al.: Drug utilization and pharmaco‑economic analysis in geriatric patients

92 (44.44%) drugs were prescribed from National and WHO Essential Drug lists, respectively. Average number of drugs prescribed per patient was 9.37 (95% CI: 9.09‑9.64). Total drug utilization during study period in terms of DDD/100 bed‑days was 19,731.81. The most commonly prescribed drugs were from the cardiovascular system (31.12%), alimentary tract and metabolism (25.72%), and blood and blood forming organs (15.66%). Utilization pattern of commonly prescribed drugs are shown in Table 1. Ranitidine (58.14%), metoclopromide (54.29%),

furosemide (41.12%), and cefotaxime (23.37%) were the commonly prescribed parenteral drugs. Etofylline + theophylline (deriphylline; 14.05%) and multivitamins (7.1%) were the commonly prescribed FDCs. Deriphylline (14.05%), carvedilol (5.77%), budesonide (5.03%), and liquid cremaffin (4.73%) were the commonly used drugs not included in National List of Essential Medicine‑2011 of India. Atorvastatin (50.59%), clopidogrel (31.5%), famotidine (19.08%), deriphylline (14.05%), and alprazolam (7.99%) were the commonly prescribed drugs not available in WHO Essential Medicine List. At least one antimicrobial drug was prescribed in 352 (52.07%) cases. Average number of antimicrobials

Table 1: Commonly utilized drugs, their ATC classification, and DDD/100 bed days in geriatric population Systems


Alimentary tract and metabolism

Proton pump inhibitor H2 receptor blocker


Omeprazole Ranitidine Famotidine Atropine

Cases (%) 149 (22) 393 (58.1) 129 (19.1) 122 (18)

Solutions producing osmotic dieresis Digitalis glycoside Adrenergic and dopaminergic agent

A03FA03 A03FA01 A04AA01 A10BA02 A10AC01 B01AC04 B01AC06 B01AB01 B01AD01 B03AA07 B03BB01 B05BC01 C01AA05 C01CA04

Domperidone Metoclopromide Ondansetron Metformin Plain insulin Clopidogrel Aspirin Heparin Streptokinase Ferrous sulfate Folic acid Mannitol Digoxin Dopamine

48 (7.1) 367 (54.3) 42 (6.2) 35 (5.2) 89 (13.2) 213 (31.5) 416 (61.5) 91 (13.5) 22 (3.3) 31 (4.6) 118 (17.5) 67 (9.9) 45 (6.7) 76 (11.2)

3.8 40.6 4.0 3.2 6.0 40.5 ‑ 17778.1 361.6 10.2 371.7 ‑ 6.0 2.1

High ceiling diuretics

C01CA07 C01CA24 C01DA08 C03CA01

Dobutamine Adrenaline Isosorbide dinitrate Furosemide

89 (13.2) 112 (16.6) 321 (47.5) 278 (41.1)

1.7 23.9 48.1 65.8

β blocking agents selective Selective CCB vascular effects‑dihydropyridines ACE inhibitor plain Statins Imidazole derivatives Glucocorticoid

C07AB02 C08CA01

Metoprolol Amlodipine

115 (17) 118 (17.5)

4.7 29.0

C09AA02 C10AA05 G01AF01 H02AB02

Enalapril Atorvastatin Metronidazole Dexamethasone

239 (35.4) 342 (50.6) 104 (15.4) 47 (7)

97.7 55.6 29.2 63.6

Third generation cephalosporins

J01DD01 J01DD04 J01MA02 N02BE01 N03AB02 N05BA01 N05BA12 R03AC02

Cefotaxime Ceftriaxone Ciprofloxacin Paracetamol Phenytoin Diazepam Alprazolam Salbutamol

158 (23.4) 71 (10.5) 93 (13.8) 58 (8.6) 103 (15.2) 51 (8) 54 (8) 59 (8.7)

12.1 12.7 13.7 11.5 9.2 6.6 13.3 2.0

Belladonna alkaloids and tertiary amines Propulsive

Blood and blood forming organs

Serotonin 5HT3 antagonist Biguanides Insulin and analogues Antithrombotic platelet aggregation inhibitor Antithrombotic enzymes Antianemic preparations

Cardiovascular system

Genitourinary and sex hormones Systemic hormonal preparation, exclusive insulin and sex hormone Anti‑infective for systemic use

Nervous system

Respiratory system

Fluoroquinolone Analgesics‑anilides Hydantoin derivatives Anxiolytic‑benzodiazepine derivatives Selective β2 adrenoreceptor agonists

ATC code A02BC01 A02BA02 A02BA03 A03A01


26.6 23.4 18.2 8.6

ATC=Anatomical therapeutic classification, DDD=defined daily dose, CCB=calcium channel blocker, ACE=angiotensin converting enzyme

Journal of Pharmacology and Pharmacotherapeutics | January-March 2014 | Vol 5 | Issue 1


Jhaveri, et al.: Drug utilization and pharmaco‑economic analysis in geriatric patients

prescribed per patient was 0.91 (95% CI: 0.82‑0.99). Total 39 different types of antimicrobials were used. The five most commonly used antimicrobials were cefotaxime, metronidazole, ciprofloxacin, ceftriaxone, and levofloxacin. Their contribution in total cost of drugs was 20.79%. Flouroquinolones  +  metronidazole  (17.61%) and third generation cephalosporin + metronidazole (16.48%) were the commonly prescribed empirical regimens. Culture and sensitivity testing was done in 88 patients.

the comparison of cost burden between common geriatric diseases. Human‑albumin, streptokinase, protein powder, enoxaparin sodium, and noradrenaline were the most five costliest drugs prescribed among 6.7% patients with 11.43% contribution to the total cost of drugs. ADRs were documented in eight (1.18%) patients. Description of ADR, causative drugs, causality, severity, and preventability assessment are mentioned in Table 4.

Average cost of treatment per patient was `540.50 (95% CI: `458.04‑622.97). Hospital and patient shared 55.28 and 44.72% of the total treatment cost, respectively. Average cost of drugs prescribed from National and WHO essential drug lists per patient were `444.73 (95% CI: `371.95‑517.52) and `348.41 (95% CI: `245.75‑401.07), respectively. There was no significant difference in cost of treatment for male and female patients (`453.95 (95% CI: `368.78‑539.13) vs `617.83 (95% CI: `481.87‑753.81); P = 0.0518). The cost of treatment was significantly higher in expired than survived patients (P 

Drug utilization pattern and pharmacoeconomic analysis in geriatric medical in-patients of a tertiary care hospital of India.

To evaluate drug utilization pattern in terms of defined daily dose along with pharmacoeconomic analysis in geriatric patients admitted in medical war...
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